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Progress notes

Davnurse Davnurse (New) New

Hi,

being fairly new to nursing, I find that I notice and am experiencing some issue contrary to what is taught in nursing school.

We were taught in nursing school that progress notes are your back up to what happened with a patient when you handled or provided services to that patient.

i was taught that regardless if the patient was residential, low or high care, or acute, emergency or whatever, if a nurse has something to do with the patient, then she must write in the progress notes, even if it was only a scheduled turn.

yet, as a new EN in the rural aspect W.A. I found that upon venturing forth to enter my involvement with residential patients under my care, that the RN on duty stopped me and clearly stated that unless something out of the ordinary happened to them, there was no need for the attending EN to write in the notes what he had done, because she the RN on duty was going to write it up anyway.

i noticed that in the progress notes there had not been an entry for some patients for over a month, and no reference to the doctors last entry of plan of care that it had even been initiated. I wondered if care had actually been given.

i questioned this and was told "check the care plan signing sheet" and yep all RNS were signing the sheet, but no one was actually entering the attended care in the progress notes.

at the end of the day the progress notes are a legal a document.

Is there anyone on here who can confirm for me that my belief or training that progress notes regardless of whether patient is acute or residential the care provided must be documented by the person providing the care?

Thank you for reading my post.

malamud69, ADN, BSN, EMT-B

Specializes in Emergency.

I work in acute care-hospital...I always write a note with every interaction. ..the situation you are describing sounds sketchy.

If I'm understanding you correctly, are you saying the nurse is going to write up and include your interaction and involvement with them on your behalf? Was the nurse present during said involvement? Excuse me if I've misunderstood somewhere.

K+MgSO4, BSN

Specializes in Surgical, quality,management.

In resi care in Australia the care plan is your progress note if you understand? By signing that the resident got a shower M/W/F as per the care paln you have documented it. If you are working in high level care you would spend half your shift documenting turns and bowel actions. That is why the care plan is there.

In resi care as well there is still a significant delineation between RN and EEN and EN and PCW/A.

The care plan is ok as long as it had been updated for the changes from the GP visit eg if the Dr wanted BP checked pre med administration then recording it on the obs chart is enough, nurses tend to double and triple document which is simply a waste of time.

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Welcome!

thread moved for best response.

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